=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093195117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER VALLEY DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2015
-----------------------------------------------------
Last Update Date | 06/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8648 OLD TROY PIKE
-----------------------------------------------------
City | HUBER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45424-1069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-236-4360
-----------------------------------------------------
Fax | 937-236-4365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8648 OLD TROY PIKE
-----------------------------------------------------
City | HUBER HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45424-1069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-236-4360
-----------------------------------------------------
Fax | 937-236-4365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. BRENDA BERNICE PHILLIPS
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 934-236-4360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 30019980
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------